Pediatric Coding Alert

Not documenting all the history and exam could cost $30 per visit Two tips will help your pediatricians get out of the "safety" CPT 99213 zone for visits that ethically deserve 99214. 

Pediatricians tend to be 99213-centric. How often do you pull a chart and think, "If the physician had simply written down a little more information or asked about another system, he could have coded a level-four visit"?

"Pediatricians have been conditioned over the years that every visit is a 99213," says Wanda L. Turner, CPC, coding specialist at Pediatric Associates of Fairfield in Fairfield, Ohio. Even when a physician's documentation supports a level-four visit, he often chooses a level-three established patient service just to be safe.

Experts say pediatricians tend to lack documentation in these areas: 4-Pronged Entries Avoid History Omissions Your pediatrician's history-taking documentation could keep her in the 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) safety zone. "Pediatricians often do a detailed history, but they rarely document it," says Victoria S. Jackson, CEO of Southern Orange County Pediatric Association in California.

What happens: In most offices, a medical assistant writes the chief complaint. The pediatrician then comes in the room and asks a series of questions. "But she forgets to put that information in the chart note," Jackson says.

Tip 1: Create a form that targets the four types of history. "The pediatrician needs a tool to trigger her memory so she'll put down all pertinent information." The form should include under the subjective (S) area:
  CC (chief complaint)
  HPI (history of present illness)
  ROS (review of systems)
  PFSH (past, family, social history). System Checklist Combats Missed Examination Another 99214 killer is not documenting all of the examination. "Often after the pediatrician finds something, she stops documenting," Jackson says.

"Because kids don't communicate as well as adults, pediatricians check more systems than family physicians or internists," Jackson says. Although a child may have ear pain, a pediatrician will check the head, nose and throat; palpitate the lymph nodes; listen to the chest; and probe the stomach.

Problem: The pediatrician will only document the ear-pain-related examination. Therefore, she thinks - and the chart note supports - a lower-level E/M service than she actually performed.

Alternatively, the pediatrician may think she performed a lower-level service because she focused only on the problem-related work. Turner's pediatricians were routinely not giving themselves enough credit for the exam work that they documented.

Solution: Turner sits down with the pediatrician and shows her the areas she overlooked. "We look at the number of 99213s the physician coded that month and see if she can increase her numbers next month," Turner says.

One system element can make the difference between meeting 99213's examination [...]